Managing Patients with Chronic Morbid Obesity, Diabetes Type 2, and Sleep Apnea
Instructions:
Case Study-A 48 year old man with morbid obesity, poorly controlled diabetes type 2, sleep apnoea and obesity ventilation syndrome
Multiple factors influence the care of patients with chronic conditions. As a Primary Heath Care nurse, it is important that care given is prioritised based on clinical and patient needs.
Prioritisation of the patient needs for care is integral to daily nursing practice. This requires integrating and collaborating different aspects of patient needs in order to maximise care activities and the effectiveness of nursing interventions.
This case study is designed to demonstrate the integration of various principles of managing care of patients with chronic conditions. Students will be expected to analyse the case scenario, identify the care needs and from the list of identified needs discuss two COMPLEX care priorities.
The case scenario
Michael Anderson is a 48 year old male with morbid obesity and type 2 diabetes who was admitted to the medical ward with poorly controlled diabetes, obesity ventilation syndrome and sleep apnoea.
Michael was referred by his GP after he presented with symptoms of shakiness, diaphoresis, increased hunger, high BGL levels and finding it difficult to breathe when he sleeps.
On the previous admission, Michael was seen by the dietician and was commenced on low energy, high protein diet (LEHP) to help him reduce weight. His GP had previously mentioned weight loss however he had never wanted to do anything about it as it ‘seemed too hard’. Michael had also been seen by the physiotherapist and was commenced on light exercises which he was to continue at home on discharge.
Michael has been discharged home, with referral to community care unit for ongoing support and follow up, after three weeks in the medical ward to manage his weight and clinical comorbidities.
Past medical history
• Obesity (weight165kgs with a BMI of 57.09m2).
• Type 2 diabetes ( diagnosed 9 years ago)
• Hypertension, (HTN)
• Depression (Diagnosed three months ago y GP).
• Sleep apnoea
• Gastro oesophageal disease reflux disease
Social History
Michael is an unemployed male who is on financial benefits. Michael lost his job three years ago as a fork lift driver at the Moranbah coal mine in far North Queensland.
Michael states that he has always been a ’biggish guy’ with his ‘normal weight’ sitting at around 95kg but since starting insulin and losing his job he has gained a significant amount of weight.
Consequently, because of his weight issues Michael has difficulty finding work due to fatigue and feeling generally ‘uncomfortable’ about his size.
Michael is a divorcee who lives alone, his daughter and son live in the same state but live in different cities and rarely visit him. He is socially isolated because he is embarrassed by his size and he rarely goes out. Michael is also finding it increasingly hard to perform activities of daily living (ADL). Michael realises that he is in the prime of his middle age life and he wants to lose weight.
Current Medication
• Insulin novamix 30/70 DB (20 units mane and 10 units nocte)
• Novarapid sliding scale
• Metformin 500mg BD
• Lisinopril 10mg daily
• Nexium 20mg daily
• Metoprolol 50mg BD
• Pregabalin (Lyrica) 50mg nocte
Last observation on discharge
• Weight 165kgs
• BP 180/92
• RR 23
• HR 102
• Sp02 RA 95% on Room Air (R/A)
Demonstrate the integration of various principles of managing care of patients with chronic conditions.Analyse the case scenario, identify the care needs and from the list of identified needs discuss two COMPLEX care priorities.
Solution
Managing Patients with Chronic Morbid Obesity, Diabetes Type 2, and Sleep Apnea
Introduction
Community nursing requires the application of effective clinical reasoning skills especially when dealing with patients suffering from chronic ailments. As a result, thinking like a nurse forms an engagement between the moral reasoning and the ability to detect impeding conditions that may deteriorate a patient. Across Australia, more than 50% of the adverse clinical events are as a result of minor errors that occur in clinical judgement. Critically evaluating a patient’s case enables a community nurse to determine and actively engage the patient in deliberating the best practice as well as reflect on the activities that are designed and which are available to improve the patient’s condition.
Case Description
Mr. Anderson is a 48-year-old male with a history of morbid obesity and type 2 diabetes. The patient has been diagnosed of obesity ventilation syndrome, sleep apnea, and it has been noticed that the diabetes is poorly controlled. The patient is said to have symptoms of shakiness, diaphoresis, increase in hunger, high levels of BGL and breathing difficulties during sleep. The patient has since been advised by both a dietitian and physiotherapist and commenced a low energy, high protein and light exercises respectively to help reduce on the weight. During the previous visits to clinics the patient also exhibited obesity symptoms by weighing 165 kgs with a BMI of 57.09m2, hypertension, depression, and Gastro esophageal disease reflux disease. Currently, the patient is on insulin novamixof 30/70 DB, Novarapid sliding scale, Metformin 500mg BD, Lisinopril 10mg daily, Nexium 20mg daily, Metoprolol 50mg BD, Pregabalin (Lyrica) 50mg nocte, and exhibit the following conditions; Weighs 165kgs, has a blood pressure of 180/92, respiratory rate of 23, 102 heartbeats per minute, and peripheral capillary oxygen saturation of 95% in Room Air.
Case Interpretation
Type 2 diabetes is caused by the combination of minimal amounts of insulin production by pancreatic B-cells. As a result, the patient may experience elevated fatty acids that accumulate in the plasma. This causes decreased transportation of glucose to the muscle cells (Bironneau et al., 2017). The patient experiences a decrease in the glucose transportation to the muscle cells and a subsequent increase in the breakdown of fats leading to increased production of hepatic glucose (Lindberg et al., 2012). In some cases, insulin resistance remains high making the patient unable to control the insulin levels. Lack of sufficient insulin secretion that can match with the degree of insulin resistance can cause a normalization disorder for the glycaemia levels.
Type 2 diabetes and obstructive sleep apnea share various clinical symptoms and may be aggravated whenever the patient is taking poor control of personal health or not following the medication instructions to the later and as advised by the physician. This is because the obstructive sleep Apnea in most cases is a comorbidity of type 2 diabetes (Aurora, 2015). In itself, OSA patients show recurrent symptoms of partial to complete obstruction of the upper airway during sleep. Other adverse consequences that patients suffer from include obesity, hypertension, cardiovascular contractions, behavioral change, encephalic alterations, and impaired tolerance to glucose (Pamidi & Tasali, 2012). The patient presented symptoms of shakiness, diaphoresis, increase in hunger, higher levels of blood glucose, and difficulties in breathing during sleep besides having increased the blood pressure levels. Blood pressure is related to the balance of flood levels in the body. An increase in blood glucose causes atherosclerosis which damages blood vessels and makes the muscles stiff especially in the legs. This may result into shaking, which the patient is said to have shown during admission. Increase in hunger is a common symptom for diabetes mellitus alongside diaphoresis.
Type 2 diabetes causes morbidity and is linked to both macro and micro-vascular complications. It is considered as an artery risk disease. The patient is suffering from artery stiffness as a result of an increase in blood glucose. According to Dawson et al. (2008), OSA is associated with atherosclerosis and initiation which causes progression of the cardiovascular disease. OSA causes hypertension, obesity, increase to morbidity. Other conditions that the patient may be likely to be suffering from include insulin resistance an impairment in glucose tolerance.
Nursing Interventions
Anderson lives an isolated life with no family. The growing body size has made the patient shy off from the public, work and is shy of appreciating the situation and the body size. Inactive physical sex activity makes it hard for the patient to recover and feel appreciated by the society. According to a psychologist in Barker (2011), a patient who feels rejected by the immediate family takes time to recover and accept the situation at hand even when it is life threatening.
For the case of Mr. Anderson, the major chronic conditions likely to simultaneously occur are hypertension and diabetes which are aggravated by the increased body mass. A s a result the patient needs to be administered to practices that will help reduce the body mass. As an initial form of treatment, the patient needs to be administered with a dietician and a physiotherapist. From the medical history of the patient, the patient was put under diet control which came up positive because the patient dropped some of the body mass. the only challenge in this process is that the patient may not be willing to follow the instructions of the dietitian (Romero-Corral et al. 2010). Mr. Anderson is a depressed man with no form of employment who may have found solace and comfort in eating what he thinks or feels brings comfort.
On the other hand, administering light exercise enabled the patient to record a drop in the body mass. Considering the age of the patient and having not been exposed to exercises in earlier years of life the patient may not be welcoming to exercises (Jordan, 2013). Financial ability is another complex attribute that makes the processes complex. Mr. Anderson has no source of income after losing his job as a driver. Some of the diet requirements may be complex to meet without any source of income. This might explain why the diabetes is poorly controlled. Likewise, physiotherapists are expensive to manage for the daily exercises and consultative services. Without a source of income, the patient may be forced to miss some sessions impairing the process to recovery.
As a community nurse attending to a patient suffering from OSA with no source of income, providing simple processes that can help the patient can help in the nursing process. As a result, offering the patient some advice applying side lying position during sleep will help the patient avoid difficulties in breathing during sleep (Nannapaneni et al. 2013). The position allows for full relaxation besides preventing blockage in the airways. Weight loss is another therapy that can help the patient to reduce the pressure on the lungs. When the patient is experiencing air drop during the day, oral mouth guards can be applied to push the tongue down and the jaw forward creating more space at the throat for air flow. A positive airway pressure therapy may be issued before applying interventional therapies like surgery to reduce abundant tissue.
Community nurses need to help the patient balance the amount of food ingested as well as the corresponding eating habits. This will initiate the weight reduction efforts. Most obese patients believe they have a very poor body image. Brusco (n.d.) notes that making the patient understand and appreciate the body image as a normal image will help uplift the esteem of the patient hence a positive attitude to nursing instructions. This also enables those patients who look down their own image to become active and participate in social activities. If the patient has applied all the lifestyle changing activities and there is no significant change, the surgical as an intervention procedure may be undertaken to reduce the excessive body mass.
A community nurse has to check the insulin levels periodically and administer antidiabetic drugs prescribed orally or administer the required amount of insulin. A lifestyle change is required and the patient has to be advised to take part in active exercise program. Administer meticulous skin care and recommend periodic ophthalmologic examinations.
Evaluations
Mr. Anderson’s health problems are closely linked to obesity. Both diabetes type 2 and OSA are complications caused by obesity. As a result, the complex care practices are pathophysiology and anesthetic administration. This is because the patient is ailing from chronic diseases that require close examinations, monitoring, and recommendation activities for major therapies where possible. According to Fredheim (2014), not every life changing activity is receptive to any patient. Administering pain relievers will always make the patients feel relieved and accommodative to the therapy. Apparently overreliance to the anesthetics may render the pain relievers unresponsive. Balancing when to give the pain relievers is a challenging practice especially when the patients are not ready to understand the drugs are to be issued after assessment (Demirel et al., 2017). Lifestyle change will help the patient reduce the body mass index hence controlling the insulin or eliminating insulin resistance (Ball & McAnulty, 2014). As compared to tracheostomy which was used to bypass the anatomical areas that collapse in the upper airways, providing continuous positive airway pressure as it was described by associates of Australia in 1982 remains the best approach to help the patient recover from OSA (Al-Goblan et al, 2014).
Conclusion
Diabetes’ association to obesity and cardiovascular failure is becoming a common problem for patients globally. This is associated to an increase in the body mass index which causes insulin resistance. Type 2 diabetes is a comorbid health condition to Obstructive sleep apnea which are associated with an increase in the resistance levels of insulin. This rises the glycemic levels or drops the level far much lower that normalcy cannot be regained. However, administering pathophysiology and anesthetic administrations are complex priorities but enable continuous positive process for patient recovery. For obesity, a lifestyle change will be required to enable the patient heal from depression, stress, poor diet and embrace exercise to keep fit.
References
Al-Goblan, A. , Al-Alfi, A., & Khan, Z. (2014). Mechanism linking diabetes mellitus and obesity. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy, 7, 587–591. Print.
Aurora, R. (2015). Obstructive sleep apnea and type 2 diabetes mellitus: examining the evidence. American College of Cardiology. Retrieved from http://www.acc.org/latest-in-cardiology/articles/2015/05/20/13/55/osa-and-type-2-diabetes-mellitus-examining-the-evidence
Ball, J. & McAnulty, G. (2014). Ignoring our evolution: the ‘pandemic’ of over-nutrition. Not simply a metabolic syndrome? Anaesthesia 2014. Retrieved from http://onlinelibrary.wiley.com/doi/10.1111/anae.12599/full
Barker, S. (2011). Obstructive sleep apnea and type 2 diabetes: a wake-up call. Journal of Diabetes Nursing, 15 (10)
Bironneau, C., Goupil, F., Ducluzeau, P., Vaillant, M., Abraham, P., et al. (2017). Association between obstructive sleep apnea severity and endothelial dysfunction in patients with type 2 diabetes. Cardiovascular Diabetology: BioMed Central. Retrieved from https://cardiab.biomedcentral.com/articles/10.1186/s12933-017-0521-y
Brusco, L. (n.d.). Critical care of the morbidly obese patient. Current Concepts in Adult Critical Care. Retrieved from http://www.learnicu.org/Lists/LearningObjectLibrary_object/Attachments/18/Chapter%209.pdf
Dawson, A., Abel, S., Loving, R., Dailey, G., Shadan, F., Cronin, J., et.al. (2008). CPAP therapy of obstructive sleep apnea in type 2 diabetics improves glycemic control during sleep. Journal of Clinical Sleep Medicine : JCSM : Official Publication of the American Academy of Sleep Medicine, 4(6), 538–542. Print.
Demirel, I., Bolat, E., & Altun, A. (2017). Obesity and anesthesia management. Retrieved from https://cdn.intechopen.com/pdfs-wm/52763.pdf
Fredheim, M. (2014). Obstructive sleep apnea in severely obese subjects: Diagnosis, association With glucose intolerance and the effect of surgical and non-surgical weight loss. Retrieved from https://www.duo.uio.no/bitstream/handle/10852/40420/PhD-Fredheim-DUO.pdf?sequence=1
Jordan, A. (2013). Adult obstructive sleep apnoea. The Lancet 383(9918), 736-747. Print.
Lindberg, E., Theorell-Haglow, J., Svensson, M., Gislason, T., Berne, C., & Janson, C. Sleep apnea and glucose metabolism: a long-term follow-up in a community-based sample. Chest. 142: 935–942
Nannapaneni, S., Ramar, K., & Surani, S. (2013). Effect of obstructive sleep apnea on type 2 diabetes mellitus: A comprehensive literature review. World Journal of Diabetes, 4(6), 238–244. Print.
Pamidi, S., & Tasali, E. (2012). Obstructive sleep apnea and type 2 diabetes: is there a link? Frontiers in Neurology, 3, 126. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3449487/
Romero-Corral, A., Caples, S., Lopez-Jimenez, F., & Somers, K. (2010). Interactions between obesity and obstructive sleep apnea: implications for treatment. Chest, 137(3), 711–719.
